Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal

Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2009

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Department of Revenue Services

State of Connecticut

(Rev. 02/09)

Municipality: __________________________

Form NAA-01

2009 Connecticut Neighborhood Assistance Act (NAA)

Program Proposal

Complete this form in blue or black ink only.

This form must be completed and submitted to your municipality for approval. All items must be completed

with as much detail as possible. If additional space is needed, attach additional sheets. Please type or

print clearly. See attached instructions before completing. Do not submit this form directly to the

Department of Revenue Services.

Part I — General Information

Name of tax exempt organization/municipal agency: ______________________________________

________________________________________________________________________________

Address: ________________________________________________________________________

________________________________________________________________________________

Federal Employer Identiﬁ cation Number: _______________________________________________

Program title: _____________________________________________________________________

Name of contact person: ____________________________________________________________

(

)

Telephone number: ________________________________________________________________

Total NAA funding requested ($250 minimum, $150,000 maximum): $ _______________________

Credit percentage for which your organization is applying:

____________60%

______________100%

(Energy conservation programs only)

Is your organization required to ﬁ le federal Form 990 or 990EZ, Return of Organization Exempt

from Income Tax?

Yes

If Yes, attach a copy of the ﬁ rst page of your most recent return.

If No, attach a copy of your determination letter from the U.S. Treasury Department, Internal

Revenue Service.

Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2009